Transcript 心包腔内的压力随之升高
冠状动脉介入损伤与急性心包填塞 Jun Dai , M.D. Coronary disease center Fuwai Heart Hospital CAMS & PUMC China 内容 冠脉血管损伤概念 冠脉穿孔分类和处理原则 心包填塞病理生理 心包填塞的临床表现 心包填塞正确处理 总结 冠状动脉介入损伤及后果 冠状动脉夹层：内膜与中膜、中膜与外膜分 离：血管壁血栓形成和管腔的闭塞 冠状动脉穿孔：亚急性心包积血或心包填塞， 尤其充分抗血小板抗凝治疗的情况下 冠状动脉破裂：急性心包积血处理不及时急 性心包填塞 Excluding case of Kawasaki d. traumatic injure Predictors Patient-related: female gender/ older age Vessel-related: tortuosity angulation calcification CTO Procedure-related: High balloon-stent ratio High inflation pressure Extremely distal location of the guidewire Device-related: Stiff wire/Hydrophilic-coated wire/cutting balloon/atheroablative devices/Ivus Classification of coronary perforation proposed Asby Ellis et al 1994 Type I: extraluminal crater without extravasation Type Ⅱ: pericardial or myocardial blush without contrast jet extravasation Type Ⅲ: extravasation through frank(≥1mm) perforation Treatment Type I 1. 15-30min careful obervation 2. no enlarge or diminish, no further action 3.protamine (1 mg per 100u heparin) ACT< 150, hemostatic PL function to restore whenⅡb/Ⅲa receptor occupany falls to<50% Type Ⅱ Perfusion balloon cather to seal UCG without delay Reversal of anticoagulation: protamine transfusion in Ps received abciximab Pericardiocentesis with tamponade/PTFEcovered stent Cardiac surgery ready for no achiveveing hemostasis Type Ⅲ Balloon inflation 5-10min to provide time for the preparation of perfusion ballon and pericardiocentesis Must be completely sealed with covered stent Immediate aggressive treatment: volume resuscitation, catecholamines, pericardiocentesis Immediate reversal of anticoagulation: protamine/ PL transfusion in abciximab-tratment Pathophysiology The pericardium, which is the membrane surrounding the heart, is composed of 2 layers. The parietal pericardium is the outer fibrous layer; the visceral pericardium is the inner serous layer. The pericardial space normally contains 2 0 - 5 0 m L o f f l u i d . 心包积液与心包填塞 心包腔内液体量增加称心包积液。 当心包腔内液体量增加到一定程度，心包腔内的压力随之升 高，达到一定限度后，引起心室舒张期充盈受阻，心排出量 降低，使血液淤滞在静脉系统，产生体循环静脉压、肺静脉 压增高等心脏受压症状，称心包填塞。 心包积液引起心包内压力升高的程度决定于：①积液的绝对 量。②积液的增加速度。③心包本身的物理特性。如果液体 的增加速度缓慢，心包被动扩张，心包腔内的积液可达2升 而无明显的压力升高。然而，如果液体量快速增加，即使不 超过150～200ml，也可引起腔内压力明显升高。在心包纤 维化或肿瘤浸润引起心包过度僵硬的情况下，少量液体积聚 也可使腔内压力快速增加。 Pathophysiologic Mechanism Intrapericardial pressures↑→ transmural distending pressures insufficient to overcome → LV diastolic filling ↓↓ ↑ intrapericardial pressure→ ↓ systemic venous return →right atrial collapse During inspiration, intrapericardial and right atrial pressures decrease because of negative intrathoracic pressure. This results in augmented systemic venous return to right-sided chambers and a marked increase in the right ventricular volume. Because the pulmonary vascular bed is a vast and compliant circuit, blood preferentially accumulates in the venous circulation, at the expense of LV filling. This results in a reduced cardiac output. Symptoms Anxiety, restlessness Discomfort, sometimes relieved by sitting upright or leaning forward. Difficulty Rapid breathing Fainting, light-headedness Pulse, weak or absent Low blood pressure Signs and tests 1. 2. 3. 4. 5. 6. Peripheral pulses may be weak or absent. Neck veins may be distended but the blood pressure may be low. HR may be over 100 Breathing may be rapid (faster than 12 breaths in an adult per minute). Bp may fall (pulsus paradoxical) when the person inhales deeply heart Sound uncharacteristically faint Fluid in the pericardial sac may show on: Coronary angiography (may show other changes also) Echocardiogram is first choice to help establish the diagnosis! ≥250ml x film 关于Beck 氏征问题 急性心包填塞三个典型征象（Beck氏三联 征）：静脉压升高、动脉压下降、心音遥远。 但有此典型征象者仅占病人的３５－４０％。 根据血流动力学的变化（机体代偿机理）， 急性心包填塞时，首先出现静脉压升高（或 尿少比动脉压降低更早出现），继而出现动 脉压下降。 急性介入血性心包填塞特点 一旦超过这些代偿限度（当心包内压力达到 约１５厘米水柱时），将出现血压下降等心 包填塞症象。此时，若不降低心包内压力 （将血液排出），当心包腔内压力超过上、 下腔静脉压力时，则发生心脏停跳，病人将 会导致死亡。在急性心包积血时，心包短时 间内积血１５０－２００毫升便足以引起压 迫，形成致命的心包填塞。 Expectations (prognosis) Tamponade is life-threatening if untreated. The outcome is often good if the condition is treated promptly, but tamponade may recur. Treatment tips Fluids are the initial treatment to maintain normal blood pressure Medications that increase blood pressure may also help sustain the patient's life until the fluid is drained. Oxygen reduces the workload on the heart by decreasing tissue demands for blood flow. Avoid mechanical ventilation and β-blockade Diuretics and nitrates are contraindicted Pericardiocentesis ！ Removal of pericardial fluid is the definitive therapy for tamponade！ Pericardiocentesis(1) The subxiphoid approach is extrapleural; hence, it is the safest for blind pericardiocentesis. A 16- or 18-gauge needle is inserted at an angle of 30-45° to the skin, near the left xiphocostal angle, aiming towards the left shoulder. When performed emergently, this procedure is associated with a reported mortality rate of approximately 4% and a complication rate of 17%. Pericardiocentesis(2) Echocardiographically guided pericardiocentesis : left intercostal space Mark the site of entry. Measure the distance from the skin to the pericardial space. Angle of the transducer Avoid the inferior rib margin Surgical Care(3) For a hemodynamically unstable patient or one with recurrent tamponade, provide the following care: Surgical creation of a pericardial window: This involves the surgical opening of a communication between the pericardial space and the intrapleural space. Take Tips Home 诊断线索：血压随体位改变而有波动 首先出现静脉压升高，继而产生动脉压下降。 强调早期诊断，果断处理。若等待动脉压 下降才诊断，则病程已至晚期。 抗休克和治疗性心包穿刺，在处理上强调 要减少不必要的诊断性检查和缩短手术前准 备时间，尽快解除心脏受压，挽救生命。 Conclusions Serious complication of PCI: Angiographic spectrum Consequences: life-threatening tamponade, MI, emergent cardiac surgery, death Type I Ⅱ Type Ⅲ